Presumptive Eligibility
FAQs

Q. How can I confirm that I will be reimbursed for a
member's presumptive eligibility service?

The eligibility verification letter clearly indicates the date a
member's coverage begins and ends and the plan to which the member
belongs, if applicable. This letter serves as the member's
identification card. In addition, a member's eligibility is
available in real time and should be viewable in the Portal at the
time the verification letter is printed and sent. If the member is
eligible under the PE Adult aid category or through the Presumptive
Eligibility for Pregnant Women (PEPW) process, providers should
contact the managed care entity (MCE) listed on the letter with
coverage and reimbursement questions.

Q. Where can a PE member receive services?

The member is not limited to receiving services only from the
provider location where he or she was determined presumptively
eligible. Most presumptively eligible members can receive services
covered under their benefit plan from any IHCP-enrolled provider.
Members eligible under the PE Adult aid category or through the
PEPW process must receive services from providers enrolled with the
member's MCE network.

Q. What if a member's eligibility for services is denied via
a pharmacy's point-of-sale system?

It may take up to three days for a member's eligibility status
to be visible in all eligibility systems, particularly in the
eligibility systems of the managed care pharmacy benefit managers.
During that time, the member is eligible to receive services. The
eligibility verification letter clearly indicates the date a
member's coverage begins and ends, and serves as a member's
identification card. If a member is enrolled with an MCE and the
pharmacy provider is unsure of the member's status, the provider
should contact the MCE listed on the eligibility verification
letter for guidance.